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Labor Dystocia
Jessica Brumley and John Caravello
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Did you know?
6 is the new 4!
FIRST STAGE OF LABOR
A prolonged latent phase (>20 hours in nulliparous women and
>14 hours in multiparous women) should not be an indication
for cesarean delivery.
Slow but progressive labor in the first stage should not be an
indication for cesarean delivery.
Cervical dilation of 6 cm should be considered the threshold for
the active phase of most women in labor. Thus, <6 cm dilation,
standards of active phase progress should not be applied.
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Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:693–711.
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Follow along: You have a copy in front of you
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Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:693–711.
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Promoting vaginal delivery in the first
stage of labor:Encourage ambulation, frequent position change, use of
birthing ball, coping with labor pain, and delaying
admission until 6 or more cm dilation
Methods to promote coping in labor include:
hydrotherapy, hot & cold packs, sterile water injections,
massage or pressure, hypnosis, TENS unit, oral nutrition.
In the stable patient who is coping well and has cervical
dilation between 3 to 6 cm, consider discharging the
patient to home after a thorough discussion about risks
and benefits of early admission using the shared decision
model discussed elsewhere in this tool kit
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Continued…
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(Cont.) Promoting vaginal delivery in the
first stage of labor:In low-risk patients, consider IA (intermittent
auscultation) for those patients without fetal heart rate
abnormalities
Unless medically required, allow adequate time for labor
to progress in the first stage and defer diagnosis of active
labor until 6 cm dilation
As long as maternal-fetal conditions permit, cesarean
delivery for a prolonged latent phase is not indicated
when slow, progressive cervical change occurs
The presence of moderate variability and accelerations
(either spontaneous or stimulated) has little association
with acidosis or neurological injury
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Hormonal Physiology of Childbearing
In environments where women feel stressed and
fearful, stress hormones (catecholamines) can
increase, reducing oxytocin and slowing the process
of the first stage labor (“fight or flight” response)
Continuous support, pain coping techniques, can
reduce stress hormones
10Buckley 2015
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Movement in Labor
Women who are upright during first stage have
shorter labors, and are less likely to have an
epidural, less likely to have a cesarean (Cochrane
Review: Lawrence et al 2013).
Women report less severe pain, more satisfaction,
fewer interventions (Priddis et al 2011).
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Peanut Ball
Decreased length of labor
Decreased CS rate in patients with epidurals
Tussey, C. M., Botsios, E., Gerkin, R. D., Kelly, L. A., Gamez, J., & Mensik, J. (2015). Reducing length of labor and cesarean surgery rate using a peanut ball for women laboring with an epidural. The Journal of Perinatal Education, 24(1), 16-24. http://dx.doi.org/10.1891/1058-1243.24.L16
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Implement Intermittent Monitoring
for Low-risk PatientsContinuous monitoring:
Increases the likelihood of cesarean
Has not been shown to improve neonatal outcomes (e.g. reduce rates of CP)
Restricts movement (and normal physiologic processes and coping)
Potentially reduces nursing
interaction/ labor support
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IA Evidence
Cochrane Review (13 RCTs, n>37,000) Increased risk of C-S, V/FAVD
No difference in perinatal mortality, CP or Apgars <7 @ 5 mins.
Neonatal seizures rare, but slightly more in IA group.
“Given that available data do not clearly support
EFM over IA, either option is acceptable in a
patient without complicatios.” ACOG, 2009
“IA is the preferred method of fetal surveillance
for healthy low risk women in labor” SOGC
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IA… When and Where?
Per ACOG and AWHONN
Latent labor q 1 hour
Active labor q 30 minutes
Second stage q 15 minutes
Listen Before
Administration of Narcotics
AROM
Transfer or discharge
Listen After
Vaginal Exam
SROM/AROM
Abnormal uterine activity
Abnormal vaginal bleed
Where?
Walking / Standing
In the shower/tub
On the ball
In the bed
With a mouse, in a house,
on chair…Anywhere!
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Second Stage
Adverse neonatal outcomes have not been
associated with duration of the second stage of
labor.
Instrument delivery can reduce the need for
cesarean.
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Promoting vaginal delivery in the second stage of labor:
If maternal-fetal conditions permit, then allow passive descent and
physiologic rest for the mother who does not have an urge to valsalva.
Allow longer pushing times if neuraxial anesthesia present
Use of maternal squat bar, side lying with an open pelvis, peanut ball,
and frequent position change facilitates fetal rotation
For slow progress, ask for bedside evaluation to diagnose possible fetal
malposition; if present, consider rotation
Consider judicious operative vaginal delivery in appropriate candidates
Consider 3 to 4 open glottis pushing efforts for 6 - 8 seconds per
contraction or pushing efforts with every other contraction when a
category 2 electronic fetal monitoring tracing exists
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Labor Support Skills to Promote
Vaginal Birth 2-Day Regional Workshops
Target audience:
PROVIDE hospital L&D staff nurses, clinical nurse specialists, educators, providers
Content:
Promoting spontaneous labor
Promoting first stage
Comfort for women
Second stage support
Fetal well-being assessment
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Research says Yes
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Retrospective analysis of 3,031 NTSV births and 72 RNs were included in the study
Tertiary care hospital
Threefold variation in cesarean rates across L&D nurses
Ranged from 8.3% to 48%
There were no differences in the gestational age, birth weight, or Apgar scores of the births amongst the four quartiles of nurses.
Edmonds et al. JOGNN 2017
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The nurse assigned to a patient may
influence the likelihood of cesarean birth
Nurses affect the clinical behaviors and labor management decisions of physicians
Nurses’ beliefs about birth
How much time nurse spends providing labor support vs other clinical duties
Skill and education level
“Nurses spend more time at the bedside than any other clinician”
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QUESTIONS?
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